Dealing with insurance claims doesn't have to be a mystery. Whether you're submitting your first claim or pushing back on a denial, understanding the process puts you in control. This guide walks through each step so you can advocate for the coverage you're entitled to.
How Insurance Claims Work
When you receive care, your provider submits a claim to your insurance company on your behalf. The insurer then reviews the claim and pays the covered portion directly to the provider. You receive an Explanation of Benefits (EOB)—not a bill—summarizing what was charged, what insurance paid, and what you owe.
Key Players in a Claim
| Role | Responsibility |
|---|---|
| Provider | Delivers care; submits claim |
| Insurance company | Reviews and pays (or denies) the claim |
| You | Review EOB; pay remaining balance; appeal if needed |
Step 1: Verify Your Coverage Before Care
Whenever possible, confirm coverage before a service:
- Call the member services number on your insurance card
- Ask if the provider and specific procedure are covered
- Request a reference number for the call
- Ask about any prior authorization requirements
Prior authorization is required for many specialist visits, surgeries, imaging, and certain medications. Your provider's office typically handles this, but it's worth confirming.
Step 2: Review Your Explanation of Benefits
Your EOB arrives after a claim is processed. Compare it to your original bill:
- Does the service date match?
- Is the provider and procedure code correct?
- Does your remaining balance match what you owe after copay and deductible?
Billing errors are more common than you might expect. If something looks wrong, contact your provider's billing department first.
Step 3: Understand a Denial
If your claim is denied, the EOB will include a reason code. Common denial reasons include:
- Not medically necessary — insurer disagrees that the service was required
- Out-of-network — provider wasn't covered under your plan
- Prior authorization not obtained — required approval wasn't secured in advance
- Duplicate claim — claim was already processed
- Coverage exclusion — the service isn't covered under your plan
Step 4: File an Appeal
You have the right to appeal any claim denial. Here's how:
Internal Appeal
- Write a letter explaining why the denial should be reversed
- Include supporting documentation: physician letters, medical records, peer-reviewed studies
- Submit within the deadline noted in your denial letter (typically 30–180 days)
- Request a written response
External Review
If the internal appeal fails, you can request an independent external review through your state insurance commissioner. The reviewer's decision is typically binding on the insurer.
Useful Language for Your Appeal Letter
"I am writing to appeal the denial of [service] dated [date], Claim #[number]. My physician, [name], determined this service was medically necessary based on [condition/diagnosis]. Enclosed please find [supporting documents]."
Step 5: Get Help If You Need It
You don't have to navigate this alone:
- Patient advocates can negotiate on your behalf
- Hospital financial counselors can review bills for errors
- Your state's insurance commissioner handles complaints and external reviews
- Nonprofit patient advocacy organizations provide free guidance for many conditions
How Bndl Care Supports You
Bndl Care's care coordinators help you understand your benefits, flag potential prior authorization requirements, and connect you with patient advocacy resources—before problems arise. Our platform tracks your appointments and care history so nothing falls through the cracks during a complex claims process.
Need help reviewing an EOB or drafting an appeal? Contact your Bndl Care coordinator or email us at contact@bndlcare.com.
